REVIEW ARTICLE

“Keep My Space”- A Review Article

Puja Khanna1,*, Sangeeta Sunda2, Sunny Mittal3
1Professor, 2,3Senior Lecturer, JCD Dental College, Sirsa

*Corresponding Author:
Email: mail@pujakhanna.com

Abstract:
Premature loss of primary teeth can result in the loss of arch length leading to malocclusion. Early interception and
prevention of malocclusion in deciduous and early mixed dentition prevents the development of pronounced anomalies in the late
mixed dentition and permanent dentition, thereby, reducing or eliminating the need for later comprehensive orthodontic
treatment. Space maintenance forms an integral part of preventive and interceptive orthodontics. This article has reviewed and
summarized some of the variables to be considered when effecting space control, the factors that dictate appliance selection, the
indications and use of space maintainers in primary and mixed dentitions.

Keywords: Space maintainers, Interceptive orthodontics, Lingual arch, Premature loss

Introduction: maintainers in primary and mixed dentitions, and

Primary teeth play a critical role in the discussed the appliances commonly used for space
growth and development of a child. In addition to maintenance.6,7,8
their role in esthetics, eating, speech, encouraging
normal growth and function, the other main function Space maintainers are broadly classified as:
is to hold space for the permanent successor until it is  Removable , fixed or semi-fixed
ready to erupt.1 Crowding and lack of space in the  Functional vs non-functional
permanent dentition are amongst the most common  Active vs passive
orthodontic problems encountered in patients. Often  Unilateral vs Bilateral
the etiology of these problems is linked to premature  Combination of above
loss of one or more deciduous teeth with
corresponding loss of space.3 The pattern of space Indications:
loss depends on many factors including age, stage 1) To prevent drifting, tipping of teeth and to
of development, which teeth have been lost, the maintain the space
presence of crowding or spacing, and occlusal 2) Prevent loss of arch length
relationships.4 Space maintainers are appliances used 3) Prevent midline shifts because of unilateral loss
to maintain space or regain minor amounts of space of deciduous tooth/teeth
lost, so as to guide the unerupted tooth into the proper 4) Restore function
position in the arch. After the premature loss of a 5) Esthetics
tooth, not only do space maintainers maintain 6) Psychological reasons
function and preserve arch length, they also maintain 7) To prevent ectopic eruption
esthetics, prevent encouragement of detrimental
habits and eliminate any potential psychological Requisites of space maintainer
damage, a child could face as a result of the 1) Should maintain mesio-distal width of tooth
premature loss of teeth. The space maintainer also 2) Simple, easy to fabricate and cost effective
allows the permanent tooth to erupt unhindered into 3) Should restore function and prevent over
proper alignment and occlusion.2 The use of space eruption of opposing teeth
maintainer appliance, or restoration of a carious 4) Should be strong enough to withstand the
primary tooth that can then act as a natural space functional forces
maintainer, may potentially obviate the consequences 5) It must permit maintenance of oral hygiene
of loss of arch length and the need for complex 6) It must not restrict normal growth and
orthodontic treatment at a later stage. 5 development which take place during the
Careful consideration of many factors is transition from deciduous to permanent dentition
required when deciding whether space maintenance
is indicated. Radiographs and space analysis can be Case selection9
very helpful.4 This article has reviewed and 1) Early exfoliation of 2nd primary molar.
summarized some of the variables to be considered 2) In case of congenitally missing 2nd premolar, it is
when effecting space control, the factors that dictate better to let the permanent molar to drift forward
appliance selection, the indications and use of space naturally and fill the space.

International Journal of Oral Health Dentistry, Jan-March, 2015;1(1):11-15 11

Khanna et al.
3) In case of congenitally missing maxillary lateral
incisor, it is better that cuspid naturally drifts.
4) Delayed eruption of permanent anterior teeth,
leads to loss of arch continuity and patient tends
to develop tongue thrust habit. A defect in
speech may accentuate and make the child
handicap psychologically.
5) In case of missing 1st permanent molar or
extracted 1st molar, let the 2nd molar move
forward and erupt into normal occlusion or hold
the space open for a permanent bridge.
Contraindications for space maintainers:10
1) When the mesiodistal width of the underlying
permanent tooth is less than the space present.
2) When the tooth is near to the crest of the ridge.
3) When the underlying permanent tooth is missing
4) When the molars are expected to drift forward.
Planning for Space Maintenance
The following considerations are important when
space maintenance is considered after the untimely
loss of primary teeth:11
1. Time elapsed since loss- if space closure occurs,
it usually takes place during the first 6 months
after the extraction. When a primary tooth is
removed & all factors indicate the need for space
maintenance, it is best to insert an appliance as
soon as possible after the extraction. Often the
best approach, if possible, is to fabricate an
appliance before the extraction & deliver it at the
extraction appointment.
2. Dental age of the patient- the chronologic age
of the patient is not so important as the
developmental age. Grown studied the
emergence of permanent teeth based on the
amount of root development as viewed on
radiographs, at the time of emergence. He found
that teeth erupt when three-fourths of the root is
developed, regardless of the child’s chronologic
age.
3. Amount of bone covering the unerupted tooth
- if there is bone covering the crown, it can be
readily predicted that eruption will not occur for
many months, a space-maintaining appliance is
indicated.
4. Sequence of eruption of teeth- the dentist
should observe the relationship of developing &
erupting teeth adjacent to the space created by
the untimely loss of a tooth.
5. Delayed eruption of the permanent tooth- in
case of impacted permanent tooth, it is necessary
to extract the primary tooth, construct a space
maintainer & allow the permanent tooth to erupt
at its normal position. If the permanent teeth in
the same area of the opposing dentition have
erupted, it is advisable to incorporate an occlusal
International Journal of Oral Health Dentistry, Jan-March, 2015;1(1):11-15
“Keep My Space”- A Review Article
stop in the appliance to prevent supra-eruption in
the opposing arch.
6. Congenital absence of the permanent tooth- if
permanent teeth are congenitally absent, the
dentist must decide whether it is wise to hold the
space for many years until a fixed replacement
can be provided or it is better to allow the space
to close. If the decision is made to allow the
space to close, there will rarely if ever be bodily
movement of the teeth adjacent to the space.
Therefore, orthodontic treatment will be needed
to guide the teeth into a desirable position.
7. Presentation of problems to parents - Explain
existing conditions & discuss the possibility of
the development of a future malocclusion if steps
are not taken to maintain the space or to guide
the development of the occlusion. Also explain
that the space-maintaining appliance will not
correct an existing malocclusion but will only
prevent an undesirable condition from becoming
worse or more complicated.11
Commonly used space maintainers:
1. Simple acrylic plate:10 non-functional space
maintainer
2. Removable partial denture/ Functional space
maintainer (fig. 1). It helps in mastication in the
posterior region, improves esthetics in the
anterior region, prevent abnormal speech and
tongue habits.11
The removable unilateral space maintainers
should not be used, although it is technically feasible
to use them. They are too small and present
swallowing and choking dangers for children.12 The
biggest problem is that children in the primary
dentition age group are very unreliable when it comes
to taking care of removable appliances, and the
appliances are apt to become lost or damaged.
In the mandibular removable functional
bilateral space maintainer, the wire attachments can
be designed for the purpose of improved appliance
retention (fig.2). A maxillary removable functional,
bilateral space maintainer is not commonly used
because of problems with the appliance not being
worn and the frequent incidence of breakage and loss
(fig. 3).
Fig.1
12
Khanna et al. “Keep My Space”- A Review Article

Fig. 2
Fig. 4

Fig. 3
FIG. 5
Advantages of removable space maintainers:
 Functional in true sense as it replaces the missing
teeth.
 Permits the teeth to be cleaned
 Maintains or restores vertical dimension
 Esthetically desirable
 Facilitates chewing and speaking
 Helps in keeping the tongue in its boundary.
 Stimulates the eruption of permanent teeth.
 Easy to fabricate and requires less chair side
time.
Disadvantages of removable space maintainers: FIG. 6
 Patient compliance is necessary and mandatory
 Appliance may be lost or broken 2) Band and loop space maintainer with occlusal
 It restricts the lateral growth of the jaw if clasps rest Fig 7: it is a modified band and loop space
are incorporated. maintainer. A small occlusal rest is designed on
 It may irritate the soft tissue. the loop wire. This is placed to prevent the
mandibular right first permanent molar from
1) Band and loop space maintainer (Fig. 4): The tipping and causing the wire to imbed apically in
band and loop space maintainer is indicated for the tissue distal to the first primary molar. Thus,
the premature loss of single, unilateral or the occlusal rest helps prevent the tipping motion
bilateral maxillary or mandibular deciduous of the first permanent molar.
molars. It adjusts easily to accommodate
changing dentition. FIG 5 and 6 shows the
indications for band and loop appliance. Space
maintenance is necessary to hold the second
primary molars in position, especially as the first
permanent molars erupt and create forces which
otherwise would move the primary molars
forward. Bilateral band and loop space
maintainers can be used in such a situation.
Fig 7

3) Stainless steel crown space maintainer

These crowns are used to restore carious primary
molars where one or two surface carious lesions
are extensive and if restoration is needed to last
more than two years. These crowns are also
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Khanna et al. “Keep My Space”- A Review Article

indicated in restoration of fractured primary 6) Semi-fixed removable type of lingual arch

molars and in localized or generalized (Fig. 9): In this type of space maintainer, the
developmental problems e.g., enamel hypoplasia, distal end of the lingual arch is placed in lingual
amelogenesis imperfecta, and dentinogenesis sheath present on the molar band and it is tied
imperfecta. In children, less than six years of with ligature. Advantage of this type of space
age, stainless steel crowns are preferable to maintainer is the ease of adjustment of the
restorations. A stainless steel wire can be appliance intra-orally.
soldered to the crown and it can be used as a 7)
crown and loop space maintainer.
4) Distal shoe space maintainer or Cantilever
type (Fig. 8): Roche advocated the Crown and
band appliance with a distal intragingival
extension. It is used to maintain space or
influence the active eruption of first permanent
molar in distal direction. Before final placement
of the space maintainer in the mouth, the
radiograph of the appliance should be made to
determine whether the tissue extension is in the
Fig. 9
proper relationship with the unerupted first
permanent molar. Final adjustment in length and
8) Pin and tube space maintainer: It is used in
contour of the shoe may be made at that time.
cases where there is early loss of primary
The soft tissue has been observed to tolerate the
incisors. Pin is allowed to slide partially out of
extension of this type of appliance well, although
the tube in response to the lateral growth of the
a small metallic tattoo in the gingiva may result.
arch.10
The depth of the intragingival extension should
9) Nance arch holding appliance (Fig. 10): Shows
be about 1-1.5 mm below the mesial marginal
a maxillary fixed bilateral space maintainer. It is
ridge of the molar, or just sufficient to capture its
similar to fixed lingual arch appliance except that
mesial surface as the tooth erupts and moves
it is used in the upper arch and there is an acrylic
forward. After the molar has erupted, the
button in the rugae region.10 It is used in
intragingival extension is removed. If the
situations where premature bilateral loss of
appliance is to be used as a reverse band and
maxillary primary teeth is present or when
loop space maintainer, it may be necessary to
leeway space must be preserved. 11,12
add a supra gingival extension to prevent the
molar from tipping over the wire.

Contraindications of distal shoe space maintainer

are as:
 If several teeth are missing
 Certain medical conditions such as blood
dyscrasias, immune-suppression, congenital
heart disease, history of rheumatic fever,
diabetes, generalized debilitation. Fig. 10

10) Gerber space maintainer (Fig. 11): The kit is

used for space maintenance or space regaining.
In case of space regaining, a compressed coil
spring or open coil spring is introduced between
the tube and the wire. Once the space is regained,
the assembly is left behind as the space
maintainer.10
Fig. 8

5) Fixed lingual arch: It is indicated in bilateral

loss of the deciduous posterior teeth, in
mandibular arch, especially if the permanent
mandibular incisors exhibit crowding.11

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Khanna et al.
Fig. 11
11) EZ space maintainer (Fig 12): EZ Space
Maintainer (Ortho Technology Inc.) is a cost-
effective, less time-consuming appliance than
traditional space maintainers. It requires no
impressions, no laboratory construction, and can
be directly bonded during one in-office visit. It is
more aesthetic, hygienic, simple and easy to use.
It provides easy maintenance of the mesio-distal
dimension of any lost, deciduous teeth and can
be used as an adjustable appliance by using the
NiTi coil included to regain some space.
Fig .12
Benefits and Harms
The potential benefits of using space maintaining
appliances include reduced prevalence or severity of:
crowding, ectopic eruption, tooth impaction, Angle's
class II or III occlusion, crossbite, excessive overbite
and overjet or midline shift. Other advantages include
the potential for considerable cost savings by
reducing the need for future orthodontic treatment1.
The potential disadvantages of using space
maintaining appliances include soft tissue
impingement, interference with eruption of adjacent
teeth, pain, plaque accumulation, caries, and broken,
dislodged or lost appliances.13 Frequent follow-ups to
check for any problems following space maintainer
insertion is recommended.4
Ongoing Monitoring and Evaluation Of In Place
Space Maintainers
The intra-oral radiographs should be taken at
appropriate intervals to evaluate the eruption status of
the permanent tooth/teeth for which a space
International Journal of Oral Health Dentistry, Jan-March, 2015;1(1):11-15
“Keep My Space”- A Review Article
maintainer has been placed. When the tooth is visible
or erupting between the wires of loop, it is time to
remove the maintainer (Fig 13). Also, if one of the
deciduous teeth supporting the appliance sheds, the
space maintainer should be removed.
Fig 13
Conclusion:
The best space maintainer is a well
maintained primary tooth. But when these important
natural space maintainers are lost, it is essential to
implement a space management strategy. Appropriate
space management therapy can save a child from
esthetic and functional disfigurement and save a
family from lot of financial expenditure in later
orthodontic treatment costs. The dentist must review
the variables and re-evaluate his decisions according
to the dynamic development of the patient's dentition
and plan accordingly.
References:
1. Peter Schopf. Indication for and Frequency of Early
Orthodontic Therapy or Interceptive Measures.
Journal of Orofacial Orthopedics. March 2003, Volume
64, Issue 3, pp 186-200.
2. Bijoor RR, Kohli K: Contemporary space maintenance
for the pediatric patient. The New York State Dental
Journal [2005, 71(2):32-35]
3. Choonara SA. Orthodontic space maintenance--a review
of current concepts and methods. SADJ. 2005
Apr;60(3):113, 115-7.
4. Durward CS. Space maintenance in the primary and
mixed dentition. Annals of the Royal Australasian
College of Dental Surgeons [2000, 15:203-205]
5. Laing E, Ashley P, Naini FB, Gill DS. Space
maintenance. Int J Paediatr Dent. 2009 May;19(3):155-
62.
6. Simon T, Nwabueze I, Oueis H, Stenger J. Space
maintenance in the primary and mixed dentitions. J Mich
Dent Assoc. 2012 Jan;94(1):38-40.
7. Law CS. Management of premature primary tooth loss in
the child patient. J Calif Dent Assoc. 2013
Aug;41(8):612-8.
8. Wright GZ, Kennedy DB. Space control in the primary
and mixed dentitions. Dental Clinics of North
America [1978, 22(4):579-601]
9. Sidney B. Finn. Clinical pedodontics-4th edition.
10. Rani M.S. Textbook of orthodontics. Revised 3rd edition.
11. Mcdonald, Avery & Dean. Dentistry for the child &
adolescent. 8th edition.
12. Peterson and Davis. Atlas of Pediatric dentistry.
13. Brothwell DJ. Guidelines on the use of space maintainers
following premature loss of primary teeth. J Can Dent
Assoc. 1997 Nov;63(10):753, 757-60, 764-6.
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